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CASE Help !!!

  • 1.  CASE Help !!!

    Posted 02-06-2019 09:46:00 AM
    patient late 30's
    CC: " i just want a permanent bright white smile and i prefer not to cut my teeth and so i want bonding"
    Ortho: " I am open to Invisalign only, i had Ortho for 3 Years in the past and it did not help much"


    Parihan Tamkin DDS
    Irving TX
    (630) 965-3861

  • 2.  RE: CASE Help !!!

    Posted 02-07-2019 09:11:00 AM
    She has some occlusal issues that are beyond the capabilities of Invisalign in my experience. Anteroposterior (AP) correction and a unilateral "scissor bite" on the right side (that picture is a little blurry so not sure if that is the case - check your f stop setting to improve depth of field) are challenging on adults even with fixed appliance therapy. So I would be cautious with orthodontic treatment. The question would be- Can this patient be treated to address her cosmetic concerns without correcting her occlusion. What are the risks? Maybe some of our members with expertise in occlusion can chime in on this case. Great post as this is a common issue we face.

    Salvatore Lotardo DDS, AAACD
    Bella Smiles
    Roslyn NY
    (631) 591-3243

  • 3.  RE: CASE Help !!!

    Posted 02-07-2019 10:07:00 AM
    Thank you for responding Sal.
    my camera was acting up and i lost some images :/ so i cropped a facial shot to show the Smile.

    However, The patient ideally doesn't care for any ortho but i still sent her to an Orthodontist for a consultation.
    Patient has an existing bridge on the upper Right extending from #2-4
    She mainly wants bonding WITHOUT PREPPING : ? or no prep veneers to achieve permanent White teeth.

    What do you tell a patient who is expecting a result without prepping?

    Parihan Tamkin DDS
    Irving TX
    (630) 965-3861

  • 4.  RE: CASE Help !!!

    Posted 02-07-2019 11:38:00 AM
    Edited by Salvatore Lotardo 02-07-2019 11:39:31 AM
    Occlusion aside, her teeth look good, so no prep or minimal prep is definitely on the table. So I would have a conversation something like this. " I appreciate that you are concerned about having your teeth cut, I believe in preserving teeth as much as possible, so we are together on that. My goal, always, is to meet my patient's expectations using the most minimally invasive approach possible. With that being said let's discuss in detail what you want to achieve and lets see if that can work with no preparation. With no preparation there may be some compromises you would have to be willing to accept, for example - significantly changing the shape or moving a tooth inward.  We can do an intra oral mock up to see how your teeth may look before ever touching anything.... etc....

    Salvatore Lotardo DDS, AAACD
    Bella Smiles
    Roslyn NY
    (631) 591-3243

  • 5.  RE: CASE Help !!!

    Posted 02-07-2019 11:07:00 AM
    Edited by David Chan 02-07-2019 11:09:33 AM

  • 6.  RE: CASE Help !!!

    Posted 02-07-2019 03:59:00 PM
    Edited by David Chan 02-07-2019 07:25:11 PM
    ​Dear Dr. Tamkin,

    Thank you for sharing this interesting case that I am confident we have all had to face in similar situations during interactions with our patients desires.
    With just going by the photos in the current occlusal scheme 3 years post orthodontic treatment, it does not appear at least without an occlusal view that there is much wear on the teeth. Also assuming that the patient does not have any functional issues with her bite this may be a treatable minimally invasively as long as the occlusion is in an "acceptable function" scenario.
    The patient appears to have an exaggerated over-jet in the anterior, moderate canting of the maxillary buccal surface on the left side and some teeth misalignment in the maxillary arch form.
    Therefore, if the patient has a stable occlusion with acceptable function you may be able to get a esthetically ideal diagnostic wax-up of the maxillary arch involving the buccal surfaces to address the patient's chief complaint of " I just want a permanent bright white smile and I prefer not to cut my teeth" and do a temporary mockup using bisacryl based on the diagnostic wax-up for the patient to evaluate the results intraorally. The results will not be ideal but if the patient approves, the case can be treated minimally invasive with some whitening, composite bonding to align and brighten the smile without having to do orthodontics which will be rather long time wise.
    Getting the patients involved with their treatment in my experience and having them understanding the risks of treatment options will build both goodwill and trust between all parties.
    Please feel free to send me any further questions you may have.


    David Chan DMD, AAACD
    Northwest Smile Designs
    Ridgefield WA
    (360) 574-8888

  • 7.  RE: CASE Help !!!

    Posted 02-07-2019 11:32:00 AM

    It is not uncommon at all for a patient to want a certain result but will not accept undertaking the necessary steps to achieve that result. Where we as dentists need to be very careful is not get blinded by taking on the challenge of helping our patients (along with the financial reward) without making it crystal clear to the patient as to what the true result will be if the patient is tying our hands by only allowing a compromise treatment and not proceeding with the recommended therapy! Without anymore info, other than what is in your thread, it appears in this case that it could be relatively simple to determine if just bonding will generate the expected result; if you are only planning on treating the anterior teeth. Either yourself or the lab should do an additive wax up on the teeth (i.e. no prepping) that will require treatment in a design the patient is looking for, i.e length, shape, etc. Following that, make a putty stint off of the wax up and then do a "down and dirty" mock-up, i.e. put some bleach shade bis-acrylic temp material, (e.g. Luxatemp), into the stint, seat it and wipe off the excess. The patient can actually leave the office, if they want, with the mock-up in their mouth to evaluate and since it is just stuck on, it can easily be peeled off. If the patient likes the esthetic result and you are comfortable with the occlusion and emergence profiles; then you can duplicate that with direct resin. To determine the final color, have the patient bleach their teeth and once that is done, place various shades of composite on the teeth, cure it (obviously without any adhesives), take some pictures and let the patient see which color is what they are looking for. If, on the other hand, the mock-up result is unacceptable, then I would tell the patient that what they are expecting and what they are allowing you to do is not possible and that they either change their expectations or change their decision about treatment options. If you do go thru the design and mock-up approach, make sure you set establish a fee you are comfortable with before starting. Remember, we as dentists need to help set realistic expectations for our patients!!



    Jack Ringer DDS, FAACD
    Advanced Smile Design
    Anaheim Hills CA
    (714) 974-0313

  • 8.  RE: CASE Help !!!

    Posted 02-07-2019 12:53:00 PM
    Dr. Tamkin, great opportunity here, being minimally invasive will be awesome - be stealthful (patient expectations are huge).
    I have found the use of aligners (Invisalign) can give us an opportunity to improve positioning and prominence of dentition, while enhancing their color with extended whitening (3-6-9months of alternating daily exposure - see Van Haywood's research).
    Also, as you are nearing the end of treatment and see areas that might benefit from a cuspal addition or a re-contoured incisal edge, you have a good foundation to work from and thus a great result to finish with.
    Best with your case.
    See you in San Diego ....
    Steven B. Andreaus, DDS, A-AACD

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    Steven Andreaus DDS, AAACD
    Raleigh NC
    (919) 546-9011

  • 9.  RE: CASE Help !!!

    Posted 02-08-2019 08:03:00 AM
    1) Nothing is "permanent".  : )


    William Schlosser DMD
    William T Schlosser DMD, Ltd.
    Springfield IL
    (217) 793-7899

  • 10.  RE: CASE Help !!!

    Posted 02-09-2019 12:53:00 PM
    Ditto Dr. Schlosser!
    It's incumbent upon the professional to do the minimum amount possible consistent with patient desires. We have become very used to cutting, impressing and having a laboratory do our work for us. Problem is, everything we do fails sooner or later. Porcelain can chip, fracture, leak at margins, wear opposing dentition, and if the patient lives long enough, require replacement at some point in time. The better we prepare the patient and the teeth, the more detailed our delivery system, overall the longer our dentistry will last. Bonded dentistry with very few exceptions, will not "look as good" as porcelain, but it's repairable and usually requires removal of less tooth structure. And bonded dentistry requires significant practice (by doing a lot of it) to master.

    Inform before you perform; tell your patient the ramifications of dental treatment, and allow your patient to make the decision. State the condition, show examples of your work to offer a solution, and charge what you're worth.
    Good luck!

    James Hastings DDS, AAACD
    Gold Rush Dental Care
    Placerville CA

  • 11.  RE: CASE Help !!!

    Posted 02-12-2019 08:54:00 AM
    Thank you so much for responding! all this info is SUPER helpful

    Parihan Tamkin DDS
    Irving TX
    (630) 965-3861

  • 12.  RE: CASE Help !!!

    Posted 02-09-2019 07:41:00 PM
    Hi all,
    these comments remind me of the MCQ tests I did in school and uni. You can easily find the wrong answer by finding some key words like: "always, never, must, permanent, all, MUST,..."
    these patients are the wrong candidate for cosmetic dentistry and most difficult ones to deal with as you might spend hours educating them  in your office and at last they think you are making excuses of your incapabilities in this field. They just want to buy some products with long life warranty without any maintenance effort with the simplest and cheapest course of treatment.